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ATTACHMENT II <br />Standard Form 270 <br /> OMB APPROVAL NO. PAGE OF <br />REQUEST FOR ADVANCE 0348-0004 PAGES <br />OR REIMBURSEMENT <br /> 1. TYPE OF PAYMENT a. X" one or hoih 6oses BASIS OF REQUEST <br /> REQUES7ED 0 qpVANCE ? REIMBURSEMENT ? CASH <br /> b. "X" the upp(icable box <br />?ACCRUAL <br /> ? <br />FINAL ? PARTIAi <br />(See instructions on back) . <br />3. EEDERAI. SPONSORING AGENCY AND ORGANIZATION ELEMENT 4. FEDERAL 4RANT OR OTHER [DENTIFYING NUMBER S. PARTIAL PAYMENT <br />TO WHICH 7'HIS REPORT IS SUBMIT7'ED ASSIGNED BY FEDERAI. AGENCY REQUES7' NUMBER FOR <br /> THIS REQUEST <br />6. EMPLOYER IDENT[fICAT10N 7. RECIPIENTS ACCOUNT g, PERIOD COVERED BY THIS REQUEST <br />NUMBER NUMBER OR <br /> IDEN7TFYING NUMBER FROM (monih, duy, yeur) TO (monih, duy, yrar) <br />9. RECIPIENT ORGANIZAT[ON 10. PAYEE (N'here check is lo be serit rfdijjereni rhan iiem 9) <br />Nance . Nanie . <br />Number Nuniber <br />amd S/reel . rurd Stree! . <br />Ci1y, Slate City, Smle <br />tmd Z/P Code : mid Z/P Code : <br />>>. COMPUTATION OF AMO[3NT OF REIMBURSEMENT/ADVANCES REOUESTED <br /> <br />PROGRAMS/FUNCTIONS ACTIVITIES - (a) (b) (c) <br />TOTAL <br />a. Total program (A.r oJdaie) <br />ouHays to day <br />$ <br />S <br />$ <br /> <br />S <br />b. Less: Cumulative program income <br />c. Net program outlays (Line a ntiims lHre b) <br />d. Fstimated net cash outlays for advance <br />Period <br />e. Total (Simi oflities c& d) <br />f. Non-Federal shaze of amount of line e <br />g. Federal share of amount on line e <br />h. Federal payments previously requested <br />i. Federal share now requested (Line g <br />minus iine h) <br />j. Advances required by 1 st month <br />month, when requested by <br />Federa( gtantor agency far <br />2nd month <br />use in making <br />prcscheduled advances <br />3rd month <br />12. ALTERNATE COMPUTATION FOR ADVANCES ONLY <br />e. Estimated Fedetal cash outlays that wi11 be made during period covered by the advance $ <br />b. Leu: Estimated balance of Federal cash on hand as of beginning of advance period <br />c. Amount requested (Line a ndnus lirre b) a <br />AUTHORIZED FOR LOCAL REPRODUCTION (Comiiiued oii Reverse) Standard Form 170 (Rev 2-92) <br />Prescri6ed by Office of Managemenl and Budget <br />Cir. No. A-102 and A-I 10 <br />Standard Form 270 (cont'd) <br />13. CERTIFICATION <br />Page 21 of 26